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The Emergency Severity Index (ESI), A Triage System: Research and
Implementation
AHRQ Annual Meeting 2008
Paula Tanabe, PhD, MPH, RNNorthwestern University, Feinberg School of
MedicineDepartment of Emergency Medicine and the
Institute for Healthcare Studies
ESI Research Team Members
• David Eitel, MD, MBA, York Hospital, Pennsylvania• Nicki Gilboy, MS, RN, FAEN, Massachusetts• Alex Rosenau, DO, Pennsylvania• Debbie Travers, PhD, RN, FAEN, North Carolina
Special acknowledgement to Debbie Travers for assistance in the development of this presentation.
Importance of Triage
• Emergency departments (ED) are crowded with long waits for physician evaluation
• Incoming patients are initially assessed by a triage nurse and assigned an acuity level– Who needs to be seen immediately?– Who is safe to wait?
• Waiting room is the highest risk area of the ED• Requires a scientifically validated triage acuity rating
system
Estimates of Triage System Choice in the United States (n=444)
Type No of EDs %
Uses triage 413 93
3 level 193 45
4 level 47 11
CTAS 32 7
ESI 134 30
Evaluating Triage SystemsValidity and Reliability
• Validity– Proxy measures for acuity include death
and hospitalization
• Reliability: Inter-rater– Will nurses rate the same patient with the
same ESI rating?– Measured with Weighted kappa () – Range (0-1, no to perfect agreement)
Early work in ESI – Late 1990’s• Drs’ Richard Wuerz and David Eitel devised the original
algorithm
• Piloted at Boston hospitals- 1998 for ages 14 and older
• ESI shown to be reliable and valid
• Produced 5 distinct categories by– Admission, length of stay– Resources, charges
• Obtained funding from AHRQ
Wuerz, Milne, Eitel, Travers, Gilboy (2000), Reliability & validity of a new 5-level triage instrument. Acad Emerg Med, 7:236-242.
AHRQ Funded Multi-Center Trial- 1999-2001
• Funded by AHRQ (Agency for Healthcare Research and Quality)
• Seven EDs in 3 states– Brigham & Women’s (Boston)– Faulkner (Boston)– UNC (Chapel Hill, NC)– York (York, PA)– Lehigh Valley (Allentown, PA)- 3 sites
• Excellent reliability (k=.78) and validity
Hospitalization AHRQ Multi-center Study
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Casemix AHRQ Multi-center Study
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ESI Version 4
ESI v.4 Materials
• Published May 2005– ESI Implementation Handbook– Educational DVDs– Total requests: 17,142 (as of April 30, 2008)
• Agency for Healthcare Research and Quality (AHRQ)– Translating research into practice– http://www.ahrq.gov/research/esi
• Free of charge– Handbook- downloadable– DVD’s
Ongoing Research
• Pediatric validation study funded by the Health Resources and Services Administration (HRSA)
• Coordinating center– UNC Department of Emergency Medicine
• Several new pediatric centers added as research sites
AHRQ Formal Evaluation• NORC, and The George Washington University • Formal assessment of the ESI training materials• Timeline
– Fall 2008 with final report to AHRQ in February 2009
• Goals– measure the acceptance of the ESI by ED personnel – assess the satisfaction training materials – compare usefulness of the ESI with other similar triage tools– determine what improvements users would like to see in the next
version of the products.
References
• Eitel D, Travers D, Rosenau A, Gilboy N, Wuerz R. The Emergency Severity Index Triage Algorithm Version 2 is Reliable and Valid. Academic Emergency Medicine. 2003; 10(10) 1070-1080.
• Tanabe, P, Travers, D, Gilboy, N, Rosenau, A, Sierzega, G, Rupp, V, Martinovich, Z, Adams, JG. Refining emergency severity Index triage criteria. Academic Emergency Medicine. 2005; 12(6): 497-501.
